Provider Demographics
NPI:1396397501
Name:CCOFS ORAL SURGERY I, LLC
Entity Type:Organization
Organization Name:CCOFS ORAL SURGERY I, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCO MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RAYLE
Authorized Official - Last Name:HOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-295-4653
Mailing Address - Street 1:8738 UNIVERSITY CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-3558
Mailing Address - Country:US
Mailing Address - Phone:704-295-4653
Mailing Address - Fax:
Practice Address - Street 1:280 ROCKY SLOPE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3908
Practice Address - Country:US
Practice Address - Phone:864-751-9972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty